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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/.pump and the Rules and Regulations of the San Joaquin Local Health District. i f { Job Address ` �{ Cit 3' y Lot Size �� .ply S R Owner's Name Address i! r Phone-3 ! • f ti Contractor to Address License No r� --� � Phone TYPE OF WELL/PUMP: NEW WELL 54 WELL REPLACEMENT C] DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR Cl17 4- R OTHER ❑�^ 0 DISTANCE TO NEAREST: SEPTIC TANK , =]/SEWER LINES f� j y t r_ DISPOSAL-FLp. Q� PROP. LINE t FOUNDATION AGRICULTURE WELL �* OT.HERL PITS/SUMP ; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTAR D SPECIFICATIONS =QRz f D Industrial Open Bottom El Manteca = Dia. of"Well Excavation �� �, Dia. of Well C_a_si66 3 XDomestic/Private ❑ Gravel Pack. %—e—Tracy ..- Type of Casing �e_ lSpecific ati isM Public f! Oth -°" 1 ]Delta Depth of Grout Sea � Type of Grout �iYKGv� I lU I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by I o f,y ri �RfepairrWork pane ❑ Type of Pump -��_ H.P. State Work Done_ .� Vljelf Destruction Well Diameter g 5 i., P .}� � Sealing Material flop 50') e� [� . Depth 6?�Ly Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ell REPAIR/ADDITION l J DESTRUCTION I 1 (No septic system permitted if puKlic sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3'feet:-- Water table depth SEPTIC TANK ❑ Type/Mfg -„ Capacityi l�No. Compartmentsif PKG!,TREATMENT PLT. ❑ Method of Disposal y i "Distance to nearest: Well Foundation Property,Ljine r F f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER.,BED '- ❑ Distance to nearest: Well Foundation= . Property Line SEEPAGE PITS U,, Depth' Size - —f— Number i J. $LIMPS}'t F CI Distance -�_to nearest: (Nell Foundation /". _ Property Line DISPOSA_ L'PONDS ❑ q -I hereb Y prepared PP ` y.certif that I have re ared this application and that the work will ba'done in accordance with Sane Joaquin county ordinances, state laws;and ,rules and regulations of the San Joaquin Local Health DistricE_ / Home owner or licensed agent's si nature certifies the folio ,., t ! g g g: "h_ertify,that in the performance of:the work for which this permit is issued, I shall not employ any person in such manner as to become subject to work an`s compensation laws of California"Contractor s hiring osub contracting signature certifies the following: "l certify that in the performance of the work for which`this permitis ued, I shall ern to tion laws of California." . p y parsons subject to workman's compensa- .. The applicant must call for all required inspections. Complete drawing on reverse side. Signed r Title: \ Date: M , FOR DEPARTMENT USE ONLY ' Yd<' Application Accepted by //// - Date `! r Area Pit or Grout Inspection by "4w, Date Fina pec y Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104' ❑Tracy 835'W5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f 7 FEE -+-AMOUNT DUE -.-AMOtdNF REMITTED-- CK-_� �� ' INFO CASH RECEIVED•9Y^----�-pATE t ` "pER1iAlT`Nt)"J 7� 2 +.EH 13-24(REV,t i n 51 �� -SR-3647 _-3 L EH 14-26 tf